By Ranit Mishori
Special to The Washington Post
Tuesday, January 16, 2007
Some of the newest players in health care are rubbing doctors the wrong way.
You may know them: those small clinics at your neighborhood Wal-Mart, Target or CVS that promise quick attention for routine visits -- sore throats, minor aches and pains, flu shots -- with no appointments needed. The clinics, which go by such names as MinuteClinic, RediClinic, QuickClinic, Medpoint Express, Curaquick and MediMin, offer convenience and low price -- scarce commodities in today's medical marketplace. But while consumers are taking to the concept, physician resistance is building.
"The quickest, most convenient medical care is not always the best," says Caroline Van Vleck, a Washington pediatrician. Particularly, she and a growing chorus of primary care physicians contend, when it comes to children.
But even as many doctors sound the alarm, others are scrambling to adapt. Increasingly, the discussion among physicians like me is focusing on how to compete with the new clinics -- even if that means stealing a trick or two.
Not that many are convinced this trend is good for patients. Within the past six months, the American Medical Association and the American Academy of Pediatrics have both decried it.
"Convenience is not enough," the AMA lamented in a recent editorial. Comparing the mini-clinic phenomenon to kudzu -- the tree-strangling vine rampant in the South -- the AMA complained these new services are spreading too far, too fast. In a policy statement issued this fall, the AAP "opposes retail-based clinics as an appropriate source of medical care for infants, children, and adolescents and strongly discourages their use."
As traditional medicine sees it, when a young patient gets hurry-up treatment for a single symptom at a retail-based clinic (RBC), also known as a convenient care clinic (CCC), the process leads to "fragmentation of care."
Physicians such as Robert Corwin, who recently served as a director of the AAP, worry about a child's receiving medical care at different places by different providers -- most retail clinics are staffed by nurse practitioners and physician assistants, not doctors -- who may not communicate with one another.
Children, he argues, need a "medical home" -- a place offering comprehensive, family-centered, coordinated, continuous care, in which a doctor knows the patient over time.
"Parents may say, 'It's just a sore throat,' " explains Corwin, a practicing pediatrician in Rochester, N.Y. But those sore throat visits, he says, are a pediatrician's "vehicle to continue developing the relationship with the family."
Van Vleck agrees: "When I see a kid for a sore throat, I get to go through their chart. If they have a little bit of scoliosis I might check their spine. I will check their immunization record. We go over the record, and we try to go over what's going on besides the sore throat, or besides the ear infection."
Bottom line, Corwin says: "These [clinics] are not appropriate for children."
James Woodburn, chief medical officer of MinuteClinic, emphatically disagrees:
"We've been around for nearly seven years now . . . with almost no adverse events," he says. "We have a long track record of quality medical care," he continues, expressing pride "with our ability to provide convenient and extremely high-quality and cost-effective care."
Rockville parent Meredith Salamon is inclined to agree. Dropping into a MinuteClinic in a nearby CVS pharmacy last month to get flu shots for four of her five children, she says she was in and out in 15 minutes. "The cost was good, and the location was good, so it was easy and quick," she said. By contrast, she says, the family's more expensive traditional doctor "kept running out" of flu vaccine and keeps inconvenient hours.
From a business point of view, RBCs look like a success story. Five years after the first RBC was founded by a Minnesota doctor, there are now about 200 nationwide. A survey last summer by the California HealthCare Foundation projected the number will reach several thousand by the end of 2007.Filling a Need
Fueling this growth, says Anne Pohnert, MinuteClinic's manager of operations for the Washington area, is the appeal of lower cost, speed, convenience and after-hours availability.
"Many patients would like to get in to see their primary care physician, but when they call, there is no appointment available," she says. Choosing an urgent care center or emergency facility may involve "a long wait and considerably more cost," she adds. "We believe that a visit to MinuteClinic instead of an ER on a Friday evening for a five-minute strep test is a win-win for patients and insurers trying to save time and health-care costs."
To contain costs, the typical retail clinic is a bare-bones affair, usually a small room with a few chairs, a cabinet or two and perhaps, but not always, an examining table.
On-site medical staff usually consists of a single nurse practitioner or physician assistant. A doctor is generally available for phone consults only. Prices are posted for all to see. Some typical fees in Maryland's MinuteClinics: $30 for a flu shot, $59 for a strep test, $49 to diagnose and prescribe treatment for an ear infection. Also posted prominently are ad slogans that capture the concept: "You're Sick, We're Quick," "Get Well, Stay Well -- Fast," "On the spot relief," "Great Care, Fast, and Fair."
MinuteClinic, which began operating here two years ago, now runs a dozen clinics in Maryland and 146 nationally, making it the industry leader. In the Washington area, it has recorded about 80,000 patient visits, according to its chief executive, Michael Howe. (CVS acquired MinuteClinic in September and operates it as a wholly owned subsidiary.)
Even their critics concede the clinics are tapping public frustration with traditional delivery of health care.
"The retail clinics are sending physicians a message that our current model of care is not always easy to access," says Rick Kellerman, president of the American Academy of Family Physicians.
This summer the nine partners of Spring Valley Pediatrics, a District-based practice founded 80 years ago, huddled to develop their response to RBCs.
According to Van Vleck, a member of the practice, the meeting was prompted in part by two cases that had come through the group's doors -- both involving children who had been treated at area RBCs. One had strep throat and the other sinusitis, but neither had been prescribed antibiotics as warranted, she says.
Further, she says, there was "poor follow-up." Most RBCs are quick to send visit reports to a patient's regular full-time physician, but in these cases, Van Vleck says, more than a month passed before reports reached the children's pediatricians. Such a lag time, she says, could endanger a patient and lead to serious complications.
One of Van Vleck's colleagues tried to contact a MinuteClinic supervisor to discuss the cases, but, according to Van Vleck, "we have yet to hear from him. It happened in August. It is now December."
MinuteClinic's Woodburn says he was not able to comment because he lacked specific information about the cases in question. "I would very much like to have an opportunity to talk to" the Spring Valley doctors, he says, to "make sure we didn't miss anything or make any kind of inappropriate or adverse treatment."
"When treating these two conditions, we adhere to the protocols of the American Academy of Family Physicians and the American Academy of Pediatrics," he says, "and only prescribe antibiotics when it's clinically warranted."
Although Woodburn concedes that mistakes can occur, he says data collected by MinuteClinic show an extremely low error rate in the diagnosis and treatment of strep throat. In a recent quality survey conducted in Minnesota, MinuteClinic received "a 100 percent rating" for the evaluation and treatment of strep throat, outscoring the Mayo Clinic.
Pohnert also expressed surprise at the two case reports. "We are all experienced nurse practitioners," she says, "who typically have years of nursing experience in various fields as well as training and experience in family practice. We don't lose that knowledge when we come to MinuteClinic. We bring it with us and use it every day to make good clinical decisions that are appropriate for patient care in our setting."
Pohnert says that RBC nurse practitioners and physician assistants are trained to handle the kinds of minor ailments (earaches, rashes, sore throats) they see, along with procedures such as shots and blood tests. "We have a certain number of diagnoses," she explains, "and only treat minor common family illnesses . . . that we have guidelines for."
Additionally, "a part of every MinuteClinic visit includes a medical history for each patient," she says. "What medications they are on, what allergies they have, and what significant medical history, if any, they have. We have strict guidelines that trigger an automatic 'refer out' if a patient has asthma or diabetes, or any of a number of other medical conditions, depending on the presenting concern."
Pohnert and several of the physicians interviewed for this article agree that patients with chronic illnesses or complex problems -- say, heart disease, high blood pressure or diabetes -- should go to their regular doctor rather than to a quick-stop clinic. "There are real limitations of what [RBCs] can do," Kellerman says.Fighting Back
Pohnert foresees a time when traditional medicine will adjust to the presence of RBCs, when the clinics will be seen as partners in maintaining public health, not threats.
The clinics, she says, also will serve as an early warning system for patients who visit for some minor ailment, only to find that their blood pressure is too high or they have sugar in their urine, a possible sign of diabetes. Securing care for people who might otherwise not have known they needed it, she says, "is gratifying."
The problem with this vision: It doesn't answer doctors' fears about RBCs' "encroaching on the economics of their business," as Kellerman puts it.
Kellerman is among those convinced that RBCs are here to stay and that traditional medicine will need to adapt to survive. Such adaptations are already occurring, he says, with doctors expanding office hours, opening on weekends and offering online scheduling.
The American Academy of Family Physicians has launched a national project ( http://www.transformed.com) to test new ways to improve care and make primary care practices more welcoming to patients.
"You can't stop the train," Corwin says. "Our colleagues are going to have to step up to the plate and change how they practice so that there's no reason not to go to your own doctor."
Van Vleck echoes the sentiment: "If you have a doctor that knows you, that you've been going to for years, there should be no reason to use retail-based clinics."
Pohnert continues to argue that it doesn't have to be a contest. She runs through the list of patients she sees whose circumstances, in her view, present no threat to traditional practice: "people who are traveling, visiting family in the area or here on vacations" -- not to mention people -- mostly young adults -- who don't have regular physicians. Or those without health insurance. "There are so many people and not enough providers," she says.
For now, she says, "we'll share. There's room for everybody. The consumers want to have choice, and we'll work together. We'll make it work for everybody." ·
Ranit Mishori, a family medicine resident at Georgetown University/Providence Hospital, recently wrote for the Health section about claims that you can improve your vision through exercise. Comments:firstname.lastname@example.org.